Gloria Lemay on natural birth, breastfeeding, and other womanly matters

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VBAC and the Doula

The doula must do some advanced planning about support of women having vaginal births after cesarean (VBAC) as opposed to a first baby. Women who are planning a VBAC have emotions and fears about giving birth that are justifiably heightened. They have experienced major abdominal surgery and all the problems that follow. The VBAC client will take more time and patience than your other clients.

Prenatal Preparation

A full history of the events leading to the cesarean is very important. With a VBAC client, ask her to get her operative records, nurse’s notes, anesthetist’s report, pediatric report–get all the records and go over them
thoroughly. You may need to ask a friendly nurse or midwife to answer questions that arise. Often the couple did not get full or accurate information about what was going on. Sometimes there’s a little “clue” as to what went wrong that could help to prevent a cesarean from reoccurring.
Sometimes there is a big chunk of information that didn’t get communicated. I saw one set of records where the only indication for the cesarean was the note from the obstetrician that “this woman is a natural childbirth
fanatic.”

Another set of cesarean records had no indicator whatsoever of why the woman received abdominal surgery when she had given birth at l9 years old. When she told her parents that the midwife was perplexed and could see no reason for the surgery, her father admitted to her that he had stayed in the
visitor’s lounge all day and had been verbally threatening to the doctor:“If anything happens to my daughter, I’ll sue you!” This helped the daughter to understand what had happened to her and also helped her to be firm with her father that he was to be nowhere near her VBAC birth.

Helping the frightened VBAC father

A VBAC father is in a horrible place because, despite the fact that his wife had an operation and a long recovery, he still got a live wife and baby at
the end of it all. VBAC dads are often “fantasy bonded” to the medical system and terrified of childbirth in general.

Often, the role of the doula at the actual birth is to keep the father from hyperventilating. The mother tends to need a lot of emotional support during the pregnancy but then gets into the birth and does well. The father
remembers all the drama of the first birth and becomes very tense as the birth progresses. Have compassion. It is very heartwarming to see how
wonderful it is for the couple to succeed in having a vaginal birth. Make sure he eats, drinks and sleeps. I think that Nancy Wainer Cohen’s books “Silent Knife” and “Open Season” are essential reading for the VBAC father.
There are lots of good stories by men who have been through the fear and speak poignantly about the joys of having an intact wife after birth.

Progress in VBAC birth

If the woman has dilated past five centimeters in the first birth, plan for it to be fairly fast-like any second baby. If the
woman has not gone into the birth process or not dilated past five the first time, that’s all right, she’ll still give birth vaginally, but have extra doulas on call to bring fresh energy if the others get discouraged or tired.
Plan for it to be like going to two births in a row.

The point that the woman reached in her first birth is often a psychological hurdle for her. If she dilated to six centimeters the first time, the news that she is seven or eight will be a relief and a breakthrough. One of my clients, a minister’s wife, said over and over again in her pregnancy: “I just want to feel what pushing is. If I only get to push, I’ll be happy. I
just want to know what other women mean when they say they had to push.”
She’d had a Bandl’s ring in the first birth process and the cesarean was done at five centimeters. We were praying that the complication wouldn’t repeat. She dilated smoothly and began to push. With each push she would
exclaim “Thank you Jesus, thank you Jesus!” What a wonder it was to watch her push out the baby, a girl whom she named Faith.

Avoiding Pitfalls

All humans have a certain propensity to self-sabotage, and the VBAC woman must be guarded against her own self-defeating patterns. The doula must be
bold in pointing out ways that the woman is repeating mistakes—there’s no place for being “nice” if it will mean another cesarean. An example of this:
If the woman had a cesarean with five support people, dissuade her from having extra people at her VBAC birth.

Privacy and quiet are a must, and you may have to be very forceful about setting up logistics before the birth so that the woman can birth in peace.
In short, the VBAC is high priority because the woman’s whole obstetrical future rides on its success. Show the couple lots of videos of beautiful VBAC births because one video is worth a thousand words. If you don’t have your own, I recommend “Gentle Birth Choices” by Barbara Harper, which
includes footage of a beautiful VBAC birth.

Art therapy is helpful in creating the environment before the birth day. I place a big sheet of
drawing paper in front of the father and mother with lots of colored pencils and instruct them to, “Draw your birth cave” or, “Color your birth.” When they are finished, I write the date on the two drawings and put them away in my files. After the birth, we take them out and are amazed at the details
that were drawn weeks before and later manifested in the actual birth.

Questions to ask the VBAC woman:

* How do you know that this time you will give birth vaginally?
* What would make this birth really special for you?
* How will you know you really got the birth you wanted? (i.e. What will the evidence be?)
* What can we do this week to make sure you have a VBAC?
* If you have a wonderful, vaginal birth, who might be upset?
* What did you learn from your cesarean birth that will help you give birth vaginally this time?

All the above questions are designed to elicit a brain response in the pregnant woman that will help her picture birthing vaginally. Allow lots of time for the woman to formulate and develop her answers.

The following is a post I sent to the ICAN (International Cesarean Awareness
Network) list. It is very, very important information for ALL birthing women and can make all the difference in a VBAC birth. Read it carefully, copy it, send it to your clients. One of the VBAC women replies to my post at the end:

Subject: ICAN: Tip for birth

I wanted to write to those of you who are pregnant to tell you something that has been running through my mind all day about how you can be successful with your VBAC births. Many births begin in the night…. woman will get up to pee, feel her membranes release and then an hour later begin
having sensations fifteen minutes apart. Because we think of birth as a family/couple experience, most women will wake up their husbands to tell them something’s starting and then, probably because we all hope we’ll be the 1 in 10,000 women who don’t experience any pain, we start getting the
birth supplies organized, fill up the water tub, etc.

I have seen so many births that take days and days of prodromal (under 3 cms. dilation) sensations and they usually begin this way. The couple distracts themselves
in that early critical time when the pituitary gland is beginning to put out oxytocin to dilate the cervix. Turning on the light, causes inhibition of the oxytocin release. Many couples don’t call their midwives until they’ve got sensations coming 5 minutes apart at 7:00 a.m. but they’ve been up since
midnight timing every one of the early sensations. If they had called their midwife at midnight she would have said “Turn off the light and let your husband sleep as much as possible through the night. You, stay dark and quiet. Take a bath with a candle if it helps and call me back when you think
I should come over.”

That first night can make all the difference and yet so many couples act like it’s a party and don’t realize they are sabotaging their births right at the beginning. Staying up all night in the early part does two things–it
throws off the body clock that controls sleep and waking and confuses the brain AND it inhibits the release of the very hormone you need to dilate effectively.

When you begin to have sensations, I urge you to ignore it as long as you possibly can. Don’t tell anyone. Have a “secret sensation time” with your unborn baby and get in as dark a space as you can. Minimize what is
happening with your husband, family and the birth attendants. What would you rather have–a big, long dramatic birth story to tell everyone or a really smooth birth? You do have a say over your hormone activity. Help your pituitary gland secrete oxytocin to open your cervix by being in a dark,
quiet room with your eyes closed. Gloria Lemay, Vancouver

Pam wrote:

I really loved what Gloria had to say here. For me it’s all about what went wrong at my first birth (stayed up all night timing
contractions…stupid, stupid, stupid, and was totally wiped out by morning),and could have been improved at the second, when I lacked a place to stay dark and quiet. I printed it out for my dh to read, and am putting it in my file of important things to remember when labor starts, within the next
couple weeks 🙂

The Day of the Birth

The female uterus is a very strong organ that maintains its integrity and resiliency through the birth process AS LONG AS IT HAS NEVER BEEN CUT. One obstetrician explained it to me, thus: ” The nulliparous (first time birther) uterus is as strong as a rugby ball. You could kick it all over a field and it would never break. However, if you cut a rugby ball and repair
it, it will still be quite strong and may work all right in most games but one day someone will land a kick on it that breaks it open again because the integrity is never quite perfect again with a repair.”

This is the source of the obstetrical concern about VBAC births. Most women attempting a VBAC will do absolutely fine and the scar where they were cut will hold strong. It is
1 woman in 200 VBACs who will have a rupture of the scar. It is essential that VBAC births are not induced or augmented IN ANY WAY.

If the physician/midwife were to give a VBAC woman misoprostol (Cytotec),oxytocin, castor oil, strip the membranes or use any other form of inductionthen that would triple her chance of having a uterine rupture.

I believe that VBAC women have longer, gentler births because Nature is compensating for the scar. There must be no hurrying. Many midwives would be terrified to induce a VBAC woman but feel safe to attend her at home if her body is pacing itself naturally.

What are the signs of rupture? stabbing pain, unusual bleeding, decelerations of the baby’s heart, or a peculiar shape of the abdomen. In most cases, the mother is the first to know that “something’s wrong”, “something’s tearing”. IF she is unmedicated. For this reason, the VBAC
woman must be having her birth with all her senses active (no epidural). Very rarely, it is possible to have a uterine rupture without the mother feeling it.

Third stage

The doctor/midwife must be especially careful with the birth of the placenta in a VBAC because there is a slightly increased chance that the placenta might be adhered to the scar, and cord traction (pulling on the cord) could cause the uterus to prolapse. A physiologic third stage (no routine oxytocin
and no pulling) is something that should be included in the birth plan.

After the birth

After the birth, VBAC women need to be told that they can walk upright. They can’t believe that they can straighten at the waist right after giving birth. Then, they can’t believe they can do sit-ups and leg raises on day one. Usually by day three, you’ll find the VBAC woman working out at the
gym! With VBAC women, the complaints are very few in the postpartum period because they are comparing to post-surgery pain and any minor scrapes and bruises seem like nothing.

In the years following the birth, these women
will send you more clients than anyone else, and many of them will train to be doulas.

A VBAC is an amazing experience for everyone involved.Very Beautiful And Courageous (VBAC).

Want to read some quick and direct stories of VBAC births? This is a question from Midwifery Today E-News May 27, 2002

Question of the Week Responses

Q: I am seeking insight about having a VBAC after four c-sections. Does
anyone have experience with a situation like mine? I labored with all but
one of my babies and was labeled CPD. All my labors were augmented. We are
considering having another baby. -NV, midwife

====

A: I’ve had eight homebirths after three cesareans. All went well. -Kathy

A: I had an emergency c-section at 36 weeks, another that was planned in
advance (before I became informed) and an ectopic rupture, for which I was
opened up through the convenient previous scar. I was induced with Pitocin
with the third, vaginal birth successful, then a spontaneous natural birth
with a midwife attending with my fourth. We’ll have another, at home.
-Unsigned

====

A: My favorite VBAC story is about the woman who had had four previous
c-sections. For her fifth pregnancy four years ago (before everyone got so
hyper about VBACs) we discovered that she had gestational diabetes. She was
very careful about her diet. She started taking red raspberry leaf, black
cohosh and evening primrose in tincture form at 36 weeks. At 37 weeks she
went into spontaneous labor. We were not doing continuous monitoring of
VBACs then. When she reached 5 cm, she got into the tub for comfort. An hour
later she was fully dilated with the head on the perineum. She birthed a 6
lb. 10 oz.-girl in the tub.

The baby was about two pounds smaller than her previous smallest baby. In
January she had another successful VBAC despite pregnancy-induced
hypertension and gestational diabetes. Because of these and the cultural
changes and fears about VBAC, she was continuously monitored and augmented
with Pitocin. Active labor lasted about an hour and she had another
beautiful girl, weighing 6 lbs. 3 oz. No herbs this time around.

The answer to your question is yes, you can VBAC after four c-sections.
Watch your diet. Even if you are not diabetic in the pregnancy, eat well and
emphasize balanced meals. Avoid sugar. Get enough rest and help at home.
Remember that the good Lord made your body to have babies. Trust in birth.
-Tricia Shute, CNM, New Hampshire

A: While apprenticing with an experienced midwife, we had two clients who
had had multiple c-sections and both delivered vaginally at home in very
efficient, uncomplicated births. The first woman had had four c-sections,
starting with the first baby diagnosed as cephalopelvic disproportion. With
her fifth baby she had an eight-hour labor and delivered her biggest baby
yet – a baby girl just over 8 pounds. What made her situation more
significant was that this woman’s mother-in-law was at the time a state
legislator who had not supported the legalization of midwifery in our state
a few years earlier, although we are legal and VBACs are included in our
scope of practice. I don’t know that she has changed her opinion on
legalization, but the birth made a favorable impression on her.

The second woman had had 13 pregnancies (2 miscarriages, 7 cesareans for
failure to progress, 2 vaginal births all in hospital) and successfully gave
birth at home in less than five hours to a healthy 8+ pound baby boy! No
complications whatsoever. What a triumph! -Dotti Kirkpatrick, registered
midwife

A: I had one mother who gave birth vaginally after four c-sections and
another after three. Both had good deliveries. Remember that the labor
probably will be long and slow because the uterus is finding its own way
again. Stay hydrated and eat! Get as much rest as possible. Most important,
do not allow yourself to be induced or your labor augmented! Let your body
do its work in its own way and work with it. Use water, massage, whatever to
stick with it. Be sure to have only those with you who believe you can and
will give birth. You CAN! -Judy, CPM

16 thoughts on “VBAC and the Doula”

Thankyou SOOO much for this post! Both my boys ended up being c-sections after long labors. I didn’t think I had a chance of having a successful VBAC after 2, so it is so good to know that women have had VBACs successfully & with healthy babys after more than that. THANKYOU THANKYOU THANKYOU! It’s so nice to have hope again!

Gloria, thank you for this great article. This article speaks especially true to me, not only as a doula, but as a mother who has had a cesarean. Many say that my experience was different as my daughter was breech, regardless though I tried. I tried hard, but not hard enough. My husband, doula and midwifes, even the OB I was referred to were all supportive, perhaps I was the one who was not supportive enough of my own decision for a vaginal delivery. I allowed myself to allow others to scare me with all the “what ifs” and how a “breech baby can’t be delivered vaginally”, and then allowed fear of potential disabilities to effect how my daughters birth would occur. Regardless, I am still thankful for my experience because it has taught me SO MUCH. How? That the mind really does effect our body. That the hospital was the wrong place, and is the wrong place for most women to give birth. That the medical system has so much threatening them, that they intervene whenever they feel necessary. For every intervention’s pitfall, they have another intervention to improve the situation. It drives me mad, as a mother and a doula.

For my future HBAC I will have the right people surrounding me, at the right time. I will remind myself of what it is I am striving for, and why I made these decisions, and how it is that I will reach my desire. I know that my husband will be fine with all decisions I make and support them to the best he can, and remind me of what I have been fighting for. We will prepare ourselves, and those attending us, rather then them being the only ones to prepare us. Ultimately it is up to us, the power is ultimately in our hand to set up for the best possible outcome.

So, thank you, again, for this truthful, eyeopening and inspiring article and for reminding me what I am fighting for if not for others, for myself and my future next baby.

thank you so very much for this article. My first baby was born via elcs due to her being extended breech. Nobody in the hospital we were told was able to perform a vaginal delivery. She was born 3 months ago and I am still trying to get over the fact that my body wasn’t even allowed to labour.

At the beginning of my pregnancy I thought that women wanting to give birth at home are crazy. Why would you want to be away from the safety of the hospital?
Then I educated myself and WANTED to be away from the hospital. We had lots of growth scans as our baby was small (born at 4lbs 13ozs/2190g). My husband however, is not convinced it is a good idea. I will show him this for whenever we have another baby which we are planning already. 🙂

This is inspiring and useful. Thank you. I am a homebirth cesarean mom (1 child born by cesarean after beginning birthing at home). I find all of this very helpful, except two pieces of language in here which feel counterproductive: quoting the doctor about the Rugby piece (“one day someone will land a kick on it that breaks it open again because the integrity is never quite perfect again with a repair”)–that image is quite visceral and could root negatively in a woman’s mind if she is intending VBAC, as well as that line, “her uterus was total mush.” (What does that mean?) As a woman who did give birth by cesarean, I find myself having to actively and viscerally counter these images in my mind. Thank you for considering that, and thank you for the post overall.

Thanks so much, CB. You’re absolutely right about that “uterus was mush” comment by the midwife. I’ve deleted that because it is utter nonsense. I will work on the rugby ball analogy because, although it’s not the way any of us want our uterus to be described, I have found it an empowering image to keep me away from the notion of inducing VBAC women. Induction of any form can be that “kick” that you don’t want to have. So, I will find some more accurate way to say that and I truly do appreciate the fact that you read the whole post and sent me your feedback. Love Gloria

I have to agree with CB. I am hoping for a VBAC with this baby and stumbled upon this article when searching for a doula. The quote from the doctor terrifies me and literally made me shut my eyes. This is a fantastic article but I didn’t want to read something like that when I’m trying to be so positive. I was going to have my husband read it….but if I do he will definitely be skeptical of my VBAC decision after reading that. So nix on sending this to him :-/

Although I don’t agree with all the questions that you suggest a Doula ask a VBAC mama, I do like the idea that questions along these lines are discussed, although probably best to tailor them to each mama.

Another one to suggest is: “What did you learn from your previous birth that will help you achieve a birth that feels successful this time?”

Thank you for this. I so wish someone had informed me that a slower VBAC birth is better before I attempted mine. I *gave up* after 3 days because I thought the baby was too big and in a bad position and hence why the birth was going so slow. I got no emotional support. Although I am ashamed that I just gave up, on the flip side I do feel that I did amazingly well to have gone 3 days at 42 weeks.

When I got scared and weak no one was there emotionally so I weakened and my Midwife too the opportunity to take over and make it totally medicalized and ultimately another c-section.

I’m so sorry you had another csection 🙁 To me….you sound like a superstar going through 3 days of slow labor! We are so hard on ourselves. You get admiration from me! No way would I have survived three days…and I’m a pretty tough cookie. Hugs to you~xo